The Lind Gym : Your Wellness Connection
New Client Questionnaire

Please take all the time you need to complete this form. The more information you can share with us the better we can serve you.

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Country:

Contact Number:

Email Address:

Age:

Male/Female:

Weight:

Height: feet inches

What is your occupation?

Do you have a physical job or sedentary job?

How many hours a week do you work?

Explain your short term health & fitness goals?

Explain your long term health & fitness goals?

Are you currently taking any medication or under a doctor’s care? Select One ========== Yes No

Explain:

Cardio Information
How much cardio do you currently do?

Do you have access to cardio equipment? Select One ========== Yes No

If yes, name some of the equipment:

Do you want to receive information on cardio programs? Select One ========== Yes No

Strength Training Information
How much strength training do you do per week?

How many days a week can you train?

What kind of experience do you have with strength training?

Will you be training in a commercial gym or at home?

Do you want to receive information on Strength training programs? Select One ========== Yes No

Nutrition Information
What is your current diet like from breakfast to late night snack?

Do you have any food allergies or intolerance (ie. Lactose or Gluten)? Select One ========== Yes No

What is your relationship to food?

Are there any foods that you can not control overeating?

Do you go out to eat more then once a week? Select One ========== Yes No

Have you achieved success with a weight lose program before? Select One ========== Yes No

If yes, please explain:

Do you like to be creative in the kitchen? Select One ========== Yes No

Do you want to receive information on customized meal plans? Select One ========== Yes No

Please list your favorite foods from each category:

Vegetables:

Fruits:

Carbohydrates:

Meats/Proteins:

Dairy:

Please list foods that you just can’t eat for whatever reason:

Misc. information you wish to share: